Crisis Simulation to Improve Communication and Teamwork

The goal of our Perinatal Safety Initiative is to achieve zero preventable birth injuries by building a high reliability environment with a focus on teamwork and communication. Our experience indicates that adverse obstetrical events often involve breakdowns in communication and team work. The literature further reveals that communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care and the inherent limitations of human performance make communication and teamwork critically important.¹  According to JCAHO, 70% of Perinatal sentinel events reported in 2005 were due to poor communication and teamwork.²  We began crisis simulation training in our Perinatal areas in December 2005, using a set of mother-baby mannequins.  An on-site simulation training program was initiated in October 2006, with a monthly rotating schedule among our four facilities that perform labor and delivery services. Simulation sessions are conducted in a real clinical setting at each facility.  Participants are selected and notified prior to each session, and are called to a crisis scene just as they would be in a real crisis. Simulation sessions involve multidisciplinary teams from Labor and Delivery, Neonatal Intensive Care, and the Emergency Department.  Each session is followed by a debriefing. A session evaluation form is completed by a simulation team member following each scenario to measure team performance in clinical response, communication and teamwork.  Preliminary outcomes indicate that crisis simulation is an ideal tool to identify system failure and human factors, as well as to train teams to improve communication and teamwork skills, through practice of high risk, low volume clinical events on a regular basis.  Our data indicated that teams have scored high in “clinical response." However, breakdowns in communication and teamwork have also been apparent. One major communication barrier has been the use of assumptions, which has often led to misinterpretation and subsequent incorrect actions. Furthermore, teamwork has been hindered by the lack of clearly defined roles for each member. Tolerance of minor deviation in practice has at times resulted in major error. Task fixation, professional hierarchy, and fear of embarrassment have greatly discouraged information exchange and clarification among providers. Participants have reported that the training has made a tremendous difference in their awareness of teamwork techniques and communication skills, and they are better prepared to handle crisis as a result of the simulation experience. They have also validated that the debriefing is critical and represents a crucial component of “high reliability” ³ medical practice. The enthusiasm of physicians participation has been key to our success. Crisis Simulation Training, as part of the larger focus on Perinatal Safety in our hospital network, has helped us achieve a significant reduction in birth trauma rate, from a frequency of 3 per 1,000 for baseline data collected from fiscal years 2001 to 2003, to 0.2 per 1,000 for fiscal year 2006 to 2007 (p < 0.001, CI= 95%). For the last nine months of fiscal year 2007 (ending 6/30/2007), we have had zero birth trauma cases among all four facilities.